Older people present a heterogeneous mixture in illness, functionality and socioeconomics. In these patients, diabetes increase the risk of comorbidity and also of “geriatric syndrome”. In turn this increases the impact of comorbidities and also reduces the effectiveness of diabetes management.
Thus care needs to address reducing barriers to improved health but also to address issues such as cognitive impairment and impaired activities of daily living (IADL). Assessment should include health literacy, cognition, depression, medication adherence and functional ability.
There is a significant deterioration in glycaemic control in people with cognitive dysfunction, and also a higher incidence of depression in diabetes. IADL are reduced in depressed elderly and this need to be taken into account in care planning – for instance concordance with therapy can be very poor and may require 3rd party drug administration to ensure good glycaemic and blood pressure management.
Continuous glucose monitoring (CGM) may have a greater role than is currently recognized in the elderly with DM as it can often detect unrecognized hypoglycaemia. In turn the consequent reduction in falls and fractures may more than outweigh the cost of CGM. There is also a significant benefit to be gained if telemonitoring and telecare can be introduced to enable the clinical team to continue to observe these patients between clinic visits. Setting individual glycaemic goals improves glycaemic control in 32% and reduces hypoglycaemia in 19% of elderly diabetic patients.
Setting up good diabetes care for the elderly requires careful consideration of the goals of treatment and is fundamentally a balance that should maintain the basic medical ethical principal of “first do no harm”.
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